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Vaginitis, Atrophic

Thuong-Thuong Nguyen MD
Basics
Description
Vaginal epithelium thinning secondary to estrogen deficiency, resulting in
vaginal dryness and inflammation
Age-Related Factors
Atrophic vaginitis is most common in menopausal and postmenopausal
women.
May also be present postpartum in a woman who is breastfeeding
Epidemiology
1040% of postmenopausal women have symptoms of atrophic vaginitis.
Risk Factors
Menopause, either natural or surgical (oophorectomy): Decline in endogenous
estrogen
Premenopause:
o

Ovarian failure: Spontaneous or secondary to radiation or hemotherapy

Antiestrogenic medications: Tamoxifen, danazol, leuprolide,


medroxyprogesterone

Postpartum loss of placental estrogen

Lactation: Prolactin, antiestrogenic effects

Immunologic disorder

Smoking

No vaginal delivery

Pathophysiology
Circulating estrogen, mainly estradiol, helps maintain vaginal epithelium
elasticity and moistness by stimulating the production of collagen and
hyaluronic acid, respectively.
Estrogen stimulates nonkeratinized stratified squamous epithelium to thicken,
form rugae, and fill with glycogen:
o

Glycogen from sloughed cells are converted into lactic acid by


Dderlein's lactobacilli, creating an acidic environment (pH 3.55) that
is protective against urogenital infections.

Significant reduction in circulating estrogen after menopause results in:


o

Thin and less elastic vaginal epithelium, more susceptible to trauma


and irritation

Shortened and less rugated vaginal canal

~50% less vaginal secretions

Increased pH and predisposition to infection by Staphylococcus,


Streptococcus, coliforms, and diphtheroids

Associated Conditions
The genital and urinary tract share a common embryologic origin. The urethral
epithelium, bladder, pelvic muscle floor, and pelvic fascia are also estrogen
dependent. Dysuria, hematuria, urinary frequency may occur.
Diagnosis
Signs and Symptoms
The majority of women with mild to moderate vaginal atrophy are
asymptomatic.
Symptoms of atrophic vaginitis generally appear only after estrogen levels
have been low for an extended period.

Early on, women may notice a slight decrease in vaginal lubrication upon
arousal, which is one of the 1st signs of estrogen insufficiency.

Genital symptoms: Itching, dryness, burning, dyspareunia, yellow malodorous


vaginal discharge, leukorrhea, pruritus, pressure sensation

Urinary symptoms: Dysuria, hematuresis, urinary frequency, UTI, stress


incontinence

History

Menstrual history
Last menstrual period or final menstrual period

Symptoms of menopause: Hot flashes, age of mother's menopause

Obstetric history, number of vaginal deliveries, number of weeks postpartum,


lactation (breast-feeding or pumping; fully breastfeeding or supplementing)

Sexual history: Dyspareunia, sexually active, use of lubricants, STIs

Medications, chemotherapy, radiation

PMH: Immunologic disorder

Smoking

Exogenous agents that may cause or further aggravate symptoms:


o

Perfumes, powders, soaps, deodorants, panty liners, spermicides, and


lubricants may contain irritant compounds.

In addition, tight-fitting clothing and long-term use of perineal pads or


synthetic materials

Review of Systems
Special attention to GU symptoms
Physical Exam

General:
External genitalia: Loss of labial and vulvar fullness, sparsity of pubic hair,
dryness of labia, vulvar lesions, vulvar dermatoses:
o Areas of microtrauma or fissures at peri-introital area and posterior
fourchette may be seen at colposcopy, if indicated
o

Signs suggesting lichen sclerosus:

Fusion of labia minora with majora (loss of architecture)

Introital stenosis

Signs suggesting vulvar vestibulitis:

Areas of focal erythema in hymenal sulcus

Urethral:
o

Urethral caruncle, signifying eversion of urethral mucosa

Urethral polyps

Ecchymoses

Vaginal:
o

Pallor of urethral and vaginal epithelium, decreased vaginal moisture

Smooth or shiny vaginal epithelium; superficial epithelium may be lost


entirely

Loss of elasticity or turgor of skin and vaginal epithelium

Shortening and narrowing of the vaginal canal, with loss of


distensibility

Lack of/flattening of rugae

Easily traumatized epithelium with areas of traumatic subepithelial or


epithelial hemorrhage or petechiae

Pelvic organ prolapse

Rectocele

Cystocele

Tests
Lab

Serum hormone levels are generally not helpful to assess for menopause, as
FSH can wax and wane during menopausal transition.
A low level of circulating estradiol may be present, but is not clinically useful
(25 pg/mL).
Pap smear can confirm the presence of urogenital atrophy.

Maturation index: Cytologic examination of smears from the upper 1/3


of the vagina show an increased proportion of parabasal cells and a
decreased percentage of superficial cells.

An elevated pH level (postmenopausal pH levels >5), monitored by a pH strip


in the middle 3rd of the vaginal vault, may also be a sign of vaginal atrophy.

Microscopy: On microscopic evaluation, loss of superficial cells is obvious


with atrophy, but there may also be evidence of infection with Trichomonas,
Candida, or bacterial vaginitis.

Imaging
TVUS of the uterine lining that demonstrates a thin endometrium measuring between
4 and 5 mm signifies loss of adequate estrogenic stimulation.
Differential Diagnosis
Infection
Candidiasis
Bacterial vaginosis

Trichomoniasis

Metabolic/Endocrine
POF (ovarian insufficiency)
P.203
Immunologic
Contact irritation or reaction to perfumes, powders, deodorants, panty liners, perineal
pads, soaps, spermicides, lubricants, tight-fitting or synthetic clothing
Other/Miscellaneous
Vulvar lichen sclerosus
Vulvar vestibulitis
Treatment
General Measures
Moisturizers and lubricants may be used in conjunction with estrogen therapy
or as alternative treatment:
o Women who choose not to take HRT, have medical contraindications,
or experience hormonal side effects.
o

Daily moisturizer: Replens, a long acting polycarbophil-based,


bioadhesive polymer, produces a moist film over the vagina:

Relieves vaginal dryness, normalizes pH

Water-based lubricants with intercourse: Astroglide, K-Y personal


lubricant

Sexual activity is a healthful prescription for postmenopausal women:


o

Vaginal intercourse encourages vaginal elasticity and pliability, and the


lubricative response to sexual stimulation.

Fewer symptoms and less evidence of vaginal stenosis and shrinkage

Coital activity, including masturbation, associated with fewer


symptoms

Special Therapy
Complementary and Alternative Therapies
Insufficient evidence to support the use of DHEA-containing vaginal creams
Medication (Drugs)
Estrogen replacement:
o Restores normal pH levels; thickens and revascularizes the epithelium
o

Increases the number of superficial cells

May alleviate existing symptoms or even prevent development of


urogenital symptoms if initiated at the time of menopause.

Contraindications to estrogen therapy include:

Estrogen-sensitive tumors

End-stage liver failure

Past history of venous thromboembolism

Adverse effects of estrogen therapy include:

Breast tenderness

Vaginal bleeding and a slight increase in the risk of an


estrogen-dependent neoplasm

Venous thromboembolism

Increased risk of endometrial carcinoma and hyperplasia


conclusively related to unopposed, estrogen intake

Routes of administration include oral, transdermal, and intravaginal.

Dose frequency may be continuous, cyclic, or as-needed for


symptomatic relief.

The amount and duration required to eliminate symptoms depends on


the degree of vaginal atrophy.

Systemic administration of estrogen has been shown to have a therapeutic


effect on symptoms of atrophic vaginitis. Additional advantages include a
decrease in postmenopausal bone loss and alleviation of hot flashes.
o

Standard dosages of systemic estrogen, however, may not eliminate the


symptoms of atrophic vaginitis in 1025% of patients.

Systemic estrogen in higher dosages may be necessary to alleviate


vaginal symptoms.

Some women require coadministration of a vaginal estrogen product


applied locally.

Low-dose local estrogen preferred:


o

Creams, pessaries, tablets, rings similarly effective in treatment of


symptoms: Symptom relief with little endometrial proliferation

Vaginal rings, Estring or Phadia: Estradiol impregnated silastic ring is


inserted into the vagina and delivers 69 g of estradiol daily for 3
months. Favored most for comfort and ease of use.

Creams, conjugated estrogens (Premarin): Daily for 3 weeks, then


twice weekly for 12 weeks

Tablet, Vagifem: 25 g estradiol twice a week

Higher-dose local estrogen treats atrophic vaginitis, hot flushes, and


bone loss.

Vaginal ring, Femring: Releases 50100 g/d; replaced in 3


months.

Followup
Disposition
Issues for Referral
Urogynecology for urinary symptoms or pelvic organ prolapse
Prognosis
Most women get relief of symptoms with vaginal formulations of estrogen.
Systemic estrogens may require the addition of vaginal estrogen formulations.

Nonestrogen therapies are less effective for most women than estrogen.

Patient Monitoring
Assess compliance (frequency of use) and need for progestin therapy in women on
estrogen therapy:
TVUS may be helpful in assessing endometrial proliferation.
Bibliography
Bachmann GA, et al. Diagnosis and treatment of atrophic vaginitis. Am Fam Phys.
2000;61:3090.
Ballagh SA. Vaginal hormone therapy for urogenital and menopausal symptoms.
Semin Reprod Med. 2005;23(2):126140.
Botsis D, et al. Transvaginal sonography in postmenopausal women treated with lowdose estrogens locally administered. Maturitas. 1996;23:4145.
Cardozo L, et al. Meta-analysis of estrogen therapy in the management of urogenital
atrophy in postmenopausal women: Second report of the Hormones and Urogenital
Therapy Committee. Obstet Gynecol.1998;92:722.
Castelo-Branco C, et al. Management of post-menopausal vaginal atrophy and
atrophic vaginitis. Maturitas. 2005;52(Suppl 1):S46.
Leiblum S, et al. Vaginal atrophy in the postmenopausal woman: The importance of
sexual activity and hormones. JAMA. 1983;249:2195.

Nyirjesy P. Vaginitis. Washington, DC: American College of Obstetrics and


Gynecologists. Practice Bulletin, Number 72; May 2006.
Pandit L, et al. Postmenopausal vaginal atrophy and atrophic vaginitis. Am J Med Sci.
1997;314:228.
Santen RJ, et al. Treatment of urogenital atrophy with low-dose estradiol: Preliminary
results. Menopause. 2002;9:179.
Suckling J, et al. Local oestrogen for vaginal atrophy in postmenopausal women.
Cochrane Database Syst Rev. 2003;CD001500.
Willhite LA, et al. Urogenital atrophy: Prevention and treatment. Pharmacotherapy.
2001;21:464.
Miscellaneous
Synonym(s)
Urogenital atrophy
Senile vaginitis
Clinical Pearls
Women who are breastfeeding may be unaware of the possibility of atrophic
vaginitis and can benefit from education and therapy.
7580% of women with atrophic vaginitis do not inform their health care provider
of their symptoms because they believe these are part of aging.
Abbreviations
DHEADehydroepiandrosterone
FSHFollicle-stimulating hormone
HRTHormone replacement therapy
PMHPostmenopausal hormone
POFPremature ovarian failure
TVUSTransvaginal ultrasound
Codes
ICD9-CM
627.4 Postmenopausal or senile vaginitis
Patient Teaching
ACOG Patient Education Pamphlet: Vaginitis
Prevention
Regular sexual activity including masturbation is associated with fewer symptoms of
atrophic vaginitis, even without therapy.
Initiation of estrogen therapy at time of menopause may alleviate and prevent
symptoms of atrophic vaginitis.

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